Ozarks Healthcare

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47504 Based on record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) and stabilization for six patients (#4, #14, #16, #25, #28, and #29), and an appropriate, safe, transfer for one patient (#29) of 29 Emergency Department (ED) records reviewed from 11/2023 through 05/2024. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled “Physician Responsibilities in the ED,” dated 08/2021, showed the primary responsibility of the ED physician was the prompt care of patients who presented to the ED and inpatients declared to have a life-threatening emergency. The ED physician was responsible to the ED Medical Director and abided by policies and procedures set forth by the hospital, board of directors, administration and medical staff. The ED physician would perform medical and surgical procedures within their capacity necessary to prevent death or prolonged disability or injury. All patients leaving the ED would be given instructions for further care including the follow-up physician or a list of physicians they could contact for primary care services. Review of the hospital’s policy titled, “Medical Screening in the ED,” dated 10/2020, showed all patients who presented to the ED and requested examination or treatment would receive an appropriate MSE. All patients who presented with an EMC would receive necessary stabilizing treatment or appropriate transfer. EMCs would include any condition with acute symptoms of sufficient severity such that the absence of immediate medical attention would reasonably be expected to result in placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. The MSE would consist of a face-to-face evaluation by the physician or mid-level provider, completion of any diagnostic tests necessary to rule out an EMC, completion of the electronic health record, and appropriate discharge and referral instructions. Review of the hospital’s policy titled, “Pain Management,” dated 08/2022, showed the treatment of pain was based on the patient’s clinical condition, past medical history, and pain management goals. Patients in the ED would be screened and treated, or referred for treatment of pain, following an MSE. Pain was described as mild, moderate, or severe, and measured using a self-reported pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and ten means worst pain possible). Reassessment of pain was documented one hour after an intervention and when appropriate, such as a change in the patient’s condition. All newly hired staff were required to complete competency training during the orientation period and additional education was provided to all staff to improve pain assessment, pain management, and the safe use of opioids based on the needs of the patient population. Review of the hospital’s policy titled, “Emergency Medical Treatment & Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” dated 08/2022, showed the purpose was to provide a safe transfer of patients to another facility, identify guidelines for providing the appropriate setting (department) for conducting medical screening, and to identify the requirements for the EMC. An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or substance abuse) such that the absence of immediate medical attention could reasonably be expected resulting in placing the health of the individual in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ. MSE is the process of determining, with reasonable clinical confidence, whether or not an EMC exists. If the patient’s condition is outside the scope of services available, arrangement should be made to transfer the patient. A patient is stable for transfer if the treating provider attending to the patient has determined. within reasonable clinical probability, that the patient is expected to leave the hospital and be received at the second facility with no medical deterioration in medical condition. Stabilize refers to providing medical treatment of the patient’s condition necessary, within reasonable medical probability, that the medical deterioration of the condition is likely not to result from or occur during transfer of the individual. Requirements of the medical screening consists of a focused assessment based on the patient’s chief complaint sufficient to determine the presence or absence of an EMC. The MSE must provide evaluation and stabilizing treatment within the capabilities of the hospital. Please refer to 2406 and 2407 for further details. 49489”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47504 Based on interviews, record review, and policy review, the hospital failed to provide, within its capability and capacity, ongoing assessment and reassessment of a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for six patients (#4, #14, #16, #25, #28 and #29) of 29 emergency department (ED) records reviewed from 11/24/23 through 05/23/24. This failed practice had the potential to cause harm to all patients who presented to the ED. Findings included: Review of the hospital’s policy titled, “Physician Responsibilities in the ED,” dated 08/2021, showed the primary responsibility of the ED physician was the prompt care of patients who presented to the ED and inpatients declared to have a life-threatening emergency. The ED physician would perform medical and surgical procedures within their capacity necessary to prevent death or prolonged disability or injury. All patients leaving the ED would be given instructions for further care including the follow-up physician or a list of physicians they could contact for primary care services. Review of the hospital’s policy titled, “Medical Screening in the ED,” dated 10/2020, showed all patients who presented to the ED and requested examination or treatment would receive an appropriate MSE. All patients who presented with an EMC would receive necessary stabilizing treatment or appropriate transfer. EMCs would include any condition with acute symptoms of sufficient severity such that the absence of immediate medical attention would reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part. The MSE would consist of a face-to-face evaluation by the physician or mid-level provider, completion of any diagnostic tests necessary to rule out an EMC, completion of the electronic health record, and appropriate discharge and referral instructions. Review of the hospital’s policy titled, “Pain Management,” dated 08/2022, showed patients in the ED would be screened and treated, or referred for treatment of pain, following an MSE. Pain was described as mild, moderate, or severe, and measured using a self-reported pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and ten means worst pain possible). Reassessment of pain was documented one hour after an intervention and when appropriate such as a change in the patient’s condition. All newly hired staff were required to complete competency training during the orientation period. Review of the hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” dated 08/2022, showed an EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ. MSE is the process of determining whether or not an EMC exists. If the patient’s condition is outside the scope of services available, arrangements should be made to transfer the patient. A patient is stable for transfer if the treating provider attending to the patient has determined that the patient is expected to leave the hospital and be received at the second facility with no medical deterioration in medical condition. Requirements of the medical screening consists of a focused assessment based on the patient’s chief complaint sufficient to determine the presence or absence of an EMC. The MSE must provide evaluation and stabilizing treatment within the capabilities of the hospital. Review of the hospital’s policy titled, “ED Radiologic Discrepancies,” dated 10/2021, showed a combination of Ozarks Healthcare radiologists and virtual radiologists would read all radiologic studies. ED providers would complete an initial impression of their interpretation of plain film radiology studies. The radiologist would review all initial interpretations and document “agree” or “disagree” and record the final interpretation of the study. The radiologist would attempt to contact the ED physician immediately in cases of major discrepancies. When a change in treatment was needed the ED manger or a charge nurse would contact the patient about necessary changes to their treatment plan. Review of the ambulance report for Patient #4, dated 12/29/23, showed Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived at her home at 9:18 AM. She reported a large amount of blood in her stool and denied pain, nausea or vomiting. Her abdomen was soft and non-tender. She had a history of gastrointestinal (GI) bleeds and hernias (when part of the intestine bulges through the opening of abdominal muscles). The cardiac monitor (noninvasive monitor of the heart that attach to the patient’s chest and record heart rhythm) showed her heart rate was elevated between 113 and 133. Her vital signs (VS, measurements of the body’s most basic functions. Blood pressure (BP normal between 90/60 and 12/80; pulse/heartbeats normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature normal 97.8 to 99 degrees) were otherwise stable. An intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) was placed and she was given fluids. EMS transported Patient #4 to Ozarks Healthcare and gave report to Staff L, ED Charge Nurse. Review of Patient #4’s medical record from Ozarks Healthcare, dated 12/29/23, showed she arrived in the ED by ambulance at 10:42 AM. She had a past medical history of chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing). She complained of a distended abdomen ongoing for months and multiple bloody bowel movements that day. She reported she had previous exams and CTs for this issue in the past without resolution. She told the triage (process of determining the priority of a patient’s treatment based on the severity of their condition) nurse she bled “gallons of blood” while using the toilet that morning. Her assessment by Staff AA, ED Physician, showed normal bowel sounds and her abdomen was soft to palpation, non-tender, and nondistended. A computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) report of her abdomen and pelvis showed there were no acute abnormalities, no site or cause of GI bleeding. Urine and blood work showed an elevated white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood), a normal hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body), and a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). She was given IV fluids and started on an antibiotic. The discharge diagnoses were hematochezia (bright red blood in the stools) and UTI, and her condition was listed as stable. Her discharge VS showed she had no fever, her heart rate was 115, her oxygen saturation was 91%, and her blood pressure was normal. She was instructed to take the antibiotics, drink oral fluids, follow up with her primary care physician and consider seeing a GI specialist for a colonoscopy (a procedure to examine the interior of the colon with a lighted tube with a camera). On 12/30/23 Staff G, ED Physician, documented that a quality review found unreported findings in the patient’s CT. There were signs of a clot in the superior mesenteric artery (SMA, provides oxygenated blood and nutrient to the intestines) with possible bowel ischemia (restriction in blood supply to tissues, causing a shortage of oxygen needed to keep tissue alive) and a right renal (pertaining to the kidneys) infarct (tissue death due to inadequate blood supply to the affected area). The patient was notified and instructed to seek immediate medical care. After multiple attempts, the staff confirmed the patient would seek care at Hospital D and Staff G made sure that facility was aware of the patient and provided them with her relevant medical records. Review of the hospital’s untitled, undated grievance report regarding Patient #4 showed the patient complained that she was misdiagnosed by Staff AA, ED Physician. A staff member called her the day after she was treated and told her the radiologist mistakenly read one of her old CT scans. The conversation documented with the patient included several complaints. She brought up mishandling of her daughter a few years prior, she stated she lost 24 pounds of blood overnight, a staff member in the waiting room was dismissive of her bleeding and asked her why she was being hostile, she reported becoming septic (life threatening condition when the body’s response to infection injures its own tissues and organs) after being discharged, she was upset about a specialist referral she had from a separate visit, and the patient was also concerned about the dates being noted correctly in the grievance. The report concluded that Staff AA, ED Physician, was not given the correct radiology results to make an accurate diagnosis. During an interview on 05/22/24 at 10:50 AM, Staff G, ED Physician, stated that the medical director of the contracted radiology service called him and reported their quality assurance program spotted a discrepancy in Patient #4’s CT report. Staff G had the charge nurse call the patient multiple times to urge her to seek medical care. Once the patient said she would go to Hospital D, he contacted their staff to notify them the patient was coming and arranged for her scans to be available to them. When asked if this was a common occurrence, he stated that the radiology service would call occasionally to report a discrepancy found on quality checks, but rarely an error this significant. This was not the kind of error an ED physician could find looking at the scan themselves. He discussed other differential diagnoses for rectal bleeding with a normal CT scan such as bleeding diverticuli (when pockets form in the walls of the colon) or pneumatosis (the presence of gas within the wall of the small or large intestine). He stated that if the patient had a normal Hgb, he would start antibiotics and refer to primary care to discuss an outpatient colonoscopy. During an interview on 05/22/23 at 5:50 PM, Staff AA, ED Physician, stated that he did not remember Patient #4. He could not think of any other examples of radiology issues similar to her CT being misread. When asked about the patient’s condition at discharge, he was unable to find a reassessment in the chart or update on her symptoms. He stated that if he had been given the correct CT results, he would have arranged transfer to a higher level of care. During an interview on 05/22/24 at 9:45 AM, Staff N, ED Medical Director, stated that the contracted radiology service was not always reliable for good turnaround times. They might wait three hours overnight for a read. He stated there had recently been some notable “misses” in the reports. The ED physicians would sometimes have to call the radiologist to clarify reports or point out concerns. Review of Patient #28’s medical record from Ozarks Healthcare, dated 12/14/23, showed he was a 54-year-old male who presented to the ED on 12/14/24 at 6:41 AM, via EMS with complaints of shortness of breath (SOB) and chest discomfort. The chest pain was on the left side of the chest and radiated down the left arm. Staff G, ED Physician, assumed care of the patient. Patient #28 had been given an aspirin (blood thinner that can also treat pain, fever, headache and inflammation) 325 mg by mouth and 3 nitroglycerin (medication used to prevent chest pain caused by heart disease) tablets prior to arrival to the ED. His past medical history included end stage renal disease (ESRD, the final stage of kidney disease, where the kidneys can no longer function on their own) with hemodialysis (dialysis, process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions), congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues), and coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries) with stent placement (a tiny tube placed into an artery, a vein or another structure to hold the structure open). He used home oxygen at three liters via nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen). At 6:43 AM VS showed his BP 188/89, Pulse 77, RR 16, and oxygen saturation was 95%. At 6:50 AM a chest pain assessment was done and was identified as a moderate constant pain that started in the left chest and radiated down to the left arm. He rated the pain 5/10. A complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) were done and results were within normal limits. Severe acute respiratory syndrome (SARS, a rapidly spreading, potentially fatal infectious viral disease) swab was negative. At 6:58 AM a troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.001) baseline was obtained and was 71 (normal was 0-15). At 7:23 AM, VS showed BP was 188/109, pulse was 77, Respirations was 34, and oxygen saturation was 95%. At 8:51 AM, a two-hour troponin was obtained and was 80.77. An electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) was done that showed sinus rhythm (normal heart rate), possible left atrial enlargement (the left side of the heart is enlarged), possible myocardial infarction (MI, heart attack), of indeterminate age. Chest x-ray showed minimal cardiomegaly (enlarged heart). He was given hydralazine (a medication used to treat high blood pressure) 10 mg at 7:41 AM, Tylenol (a medication that treats minor pains and fever) 650 mg PO at 8:46 AM, Ativan (a medication used to treat anxiety or sleep difficulty) 2 mg IV at 8:47 am, and Labetalol (medication used to treat high blood pressure) 10 mg PO at 9:09 AM. At 9:11 AM his pain was rated 6/10 and was reassessed at 9:29 AM when he rated his pain 3/10. Staff G documented upon discharge that cardiac enzymes were within normal range, there was a slight increase in his troponin but he was no longer having chest discomfort. An angiogram (a scan that shows blood flow through arteries or veins, or through the heart) was done a year and a half ago that did not show critical disease. He suspected the troponin was elevated due to fluid overload and his chronic kidney disease. He was asymptomatic and discharged from the ED to dialysis at 9:29 AM. Review of Patient #28’s medical record from Facility F showed on 12/14/24 he presented for hemodialysis following discharge from the ED. He was very weak, came in a wheelchair, and was shaky. He complained of SOB and continued chest pain that radiated to his left shoulder and arm. He rated his chest pain 6/10 on a pain scale. Hemodialysis began at 11:26 AM and was discontinued at 1:11 PM per patient request. Patient #28 called a family member to come and take him to another hospital for his increasing chest pain. Review Patient #28’s medical record from Hospital J showed on 12/14/24 he presented with chest pain and SOB. He stated that he had been seen at Ozarks Healthcare and was told to go to dialysis and he would feel better. He did go to dialysis and continued to have chest pain. His EKG did not show any acute changes, troponin was 74, proBNP (measures the levels of a hormone in your blood, high levels of BNP can be a sign of heart failure. Normal range should be lower than 450) was 4000. Due to the patient’s extensive cardiac history, he was transferred to the ED at Hospital D for further evaluation. Review of Patient #28’s medical record from Hospital D, dated 12/14/24, showed he arrived and was admitted for a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions). Review of the hospital’s untitled, undated grievance report regarding Patient #28 showed he was seen and discharged from the ED to dialysis. He was undergoing dialysis for approximately one hour when he became unstable and was sent by EMS to Hospital J. He was stabilized, sent to Hospital D and underwent angioplasty (a procedure to repair or unblock a blood vessel) with two stents placed. The family was unhappy about the quality of care that he received from Staff G, ED Physician. Staff G reviewed the grievance and stated that he thought the elevated troponin was from the patient’s renal failure and mild CHF. Patient #28 was due for dialysis that morning and had no acute EKG changes. During an interview on 06/04/24 at 2:00 PM, Staff G, ED Physician, stated that he felt Patient #28 was in fluid overload and needed to go to his dialysis appointment. He was aware of the troponin being elevated but felt it was from his chronic kidney disease. He had reviewed his medical history and stated the patient had an angiogram approximately one and half years ago and it showed no chronic disease. He stated that he was made aware that the patient had a code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly responds to attempt to restore the heartbeat or breathing) during dialysis later that morning and was transported via EMS to another hospital. He stated that Patient #28 ended up having stents placed at Hospital D. During an interview on 06/11/24 at 12:45 PM, Staff PP, Clinic Manager from Facility F, stated that on 12/14/23 she evaluated Patient #28 and that he had been seen at the ED and was discharged with the diagnosis of fluid overload. He presented in a wheelchair and normally he ambulated into their clinic with use of a walker. During hemodialysis, he kept complaining of increased chest pain and dialysis was discontinued. He declined an emergency transport as they would take him to the nearest hospital which was Ozarks Healthcare. He did not want to go back to that hospital. He left with a family member and went to Hospital J to be evaluated. During an interview on 06/10/24 at 2:30 PM, Staff OO, Secretary from Facility F, stated that their facility will not send their patients to Ozarks Healthcare in emergency situations. She stated they have multiple patients that have been seen at the ED at Ozarks Healthcare, discharged, and then go to another facility and were admitted for a serious situation. Review of Patient #29’s medical record from Ozarks Healthcare, dated 05/23/24, showed the patient was a 21-month-old male who arrived in the ED at 12:32 AM with a chief complaint of altered mental status (mental functioning ranging from slight confusion to coma). His grandparents reported he started vomiting on 05/20/24. He was seen as an outpatient on 05/21/24, diagnosed with a GI bug and sent home. During the evening of 05/22/24, he had decreased responsiveness and seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness)-like activity. He took no medications and there was no known trauma or ingestion of toxins. He was unresponsive to painful stimuli, had stiffened posture and his gaze was deviated toward the upper right. His pupils were pinpoint, equal, round, and reactive to light. He had no meningeal signs (nonspecific reactions that may occur in a patient with meningeal irritation). The staff administered Ativan, IV fluids and dextrose (sugar). The lab results showed a critically low sodium (a type of electrolyte in the blood, normal range 135-145) of 116, high potassium 5.7 (normal range 3.5-5), critically high creatine kinase (an enzyme found in the brain, skeletal muscles and the heart, an elevated level could be associated with damage to those areas, normal range 22-198) of 1,957, and blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health. Normal ranges are considered between 70 and 100) of 69. A respiratory pathogen panel later showed the patient had adenovirus and parainfluenza (family of viruses that can cause infections in the respiratory tract). His chest x-ray showed findings that could be seen in viral conditions versus reactive airway disease. Hospital D accepted transfer of the patient to the general pediatric floor. He was originally to be transferred by air, however, weather prevented air transport and EMS was dispatched. Review of the ambulance record for Patient #29 between Ozarks Health and Hospital D showed they left the hospital on 05/23/24 at 1:55 AM. The patient was saturating well on 1L of oxygen initially. The cardiac monitor showed a normal heart rhythm. His VS abruptly changed around 2:10 AM and Staff II, Paramedic, removed the patient from his car seat, started bagging (providing positive pressure ventilation to patients who are not breathing or not breathing adequately) and gave chest compressions. During the episode, five doses of epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) were administered. After the second loss of pulses, Staff II decided to divert to Hospital C for assistance. The patient had a return of spontaneous circulation (ROSC) upon arrival to Hospital C at 2:40 AM. Review of Patient #29’s medical record from Hospital C showed the patient arrived on 05/23/24 at 2:41 AM. He was immediately triaged and seen by a provider. He was ventilated with a laryngeal mask airway (LMA, a supraglottic airway device that may be used as a temporary method to maintain an open airway) after endotracheal intubation (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) was unsuccessful. He had additional bloodwork and a chest x-ray. The physician reported the patient’s problems included cardiac arrest (when the heart suddenly and unexpectedly stops pumping), acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), aspiration pneumonia (infection in the lungs caused by food or liquid entering the lungs instead of being swallowed), low blood pressure, low blood sugar, severe dehydration (a condition caused by excessive loss of water from the body), severely low sodium, and hypoxia (not enough oxygen reaching the cells and tissues in the body). He had a low core temperature of 90.0, fixed pupils, and abnormal heart rhythms. He was shocked with a defibrillator (a device that controls the heartbeat by applying an electric current to the chest wall or heart) three times. He was given IV antibiotics, IV hypertonic saline (a crystalloid intravenous fluid with a higher sodium concentration than normal blood serum, used in critical care to treat hyponatremia, severe dehydration, and brain injury), IV dextrose and calcium chloride (an inorganic salt compound). Once stabilized, he was transferred by ambulance to the Pediatric Intensive Care Unit (PICU, unit for ill children) at Hospital D at 3:44 AM. Air transport was declined by three helicopter services due to weather. Review of the Patient #29’s ambulance report from Hospital C to Hospital D showed he was unresponsive with an LMA, an orogastric tube (small tubes placed through the mouth and end with the tip in the stomach) and IVs in place. He had antibiotics, IV fluids, and dopamine (a peripheral vasostimulant) infusing. He remained stable during transport, although he had persistent low blood pressure. Report was given to the staff at Hospital D at 4:58 AM. Review of Patient #29’s medical record from Hospital D showed he arrived on 05/23/24 at 4:59 AM. An arterial line (thin, flexible tube placed into an artery) and central venous access (long, thin, flexible tube placed in a large vein and the end of the tube sits in a large blood vessel near to or in part of their heart, allowing multiple fluids to be given and blood to be drawn) were placed by Staff FF, Pediatric Intensivist. His LMA was replaced with an endotracheal tube (ETT, a tube inserted through the mouth or nose, that extends into the lungs, to maintain an open passageway for oxygen), a rewarming machine was utilized, and he was given IV vasopressors (a group of medicines that narrow blood vessels and raise blood pressure). He had no brain activity as assessed by electroencephalography (EEG, a recording of brain activity, often used to evaluate presence of seizure activity) and absent neurological reflexes (a sudden, instinctive and involuntary reaction to stimulation). The patient’s heart stopped at 9:15 PM and resuscitation was attempted for a while. He was pronounced dead at 9:35 PM due to worsening swelling and brain death. During an interview on 06/05/24 at 8:30 PM, Staff LL, Registered Nurse (RN), stated that she was working as the triage nurse when Patient #29 was brought in by grandparents. She saw that the child was unresponsive and immediately grabbed the patient and took him back to the trauma room. She stated that the ED physician and staff took over care. She stated that the grandparents seemed to be unaware of how serious the situation was. During an interview on 06/03/24 at 4:00 PM, Staff GG, RN, stated that she was one of the nurses who cared for Patient #29 at Ozarks Healthcare. She stated that when the grandparents arrived with the patient, a triage nurse noticed immediately that he seemed unresponsive and brought him directly to a room for treatment. The family reported he had vomiting and diarrhea for three to four days and started having episodes of unresponsiveness and grinding his teeth the day before. He was persistently unresponsive to IV needles and a urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) insertion. He started to have seizure-like activity and they administered Ativan and IV fluids. The seizure activity stopped after the medication and the patient seemed post-ictal (pertaining to the period after a seizure). Staff AA, ED Physician, arranged for the patient to be transferred to Hospital D. Staff GG recalled that when she called report to Hospital D, the lab results were not back yet. They learned about the critically low sodium level, “as they were rolling out to the ambulance.” Hypertonic saline was not available at the hospital, so they kept a normal saline solution infusing during transport. She was unaware if Staff AA had discussed starting an infusion of stronger seizure medications with the accepting doctor. At the time of transport, the patient was supporting his own airway with normal VS and intubation was not considered necessary. The amount of time the patient was treated at Ozarks Health was about one hour. During an interview on 06/04/24 at 10:30 PM, Staff MM, RN, stated that Patient #29 was floppy when he first arrived, but then his body stiffened up and he began to clench his teeth. They gave a dose of Ativan, checked his blood sugar, gave him IV fluids and dextrose. The family was oddly calm and seemed unaware of the emergent situation. The ED worked as a team, but the patient clearly needed pediatric specialists. The patient was on the EMS stretcher when lab started calling with critical labs. “This was a very sick child and we did all we could to stabilize him.” During an interview on 06/10/24 at 5:45 PM, Staff AA, ED Physician, stated that Patient #29 arrived and was brought back by the triage nurse immediately. He stated that the patient was unresponsive, his body was limp and would then get stiff as if he was having a seizure. He ordered a dose of Ativan to be given for the seizure activity. He stated the nurses obtained IV access and attempted to get a urinalysis (a laboratory examination of a person’s urine) but when the nurse attempted, she was unable to get a urine sample. He stated that he immediately called Hospital D to arrange for a transfer. They attempted to call for air transport but were denied due to weather conditions. He stated they then called for an ambulance to transport the patient. At the time of discharge the patient had been stabilized as best as he could. He stated that as the patient was being wheeled out to the ambulance, they received critical lab results and he called Hospital D to let them know the results. He did not add any additional orders for transfer after receiving the critical lab results. During an interview on 06/05/24 at 10:20 AM, Staff NN, Pediatric Hospitalist from Hospital D, stated that he accepted Patient #29 for transfer to the general pediatric floor. The report he received from Staff AA, ED Physician, was that the patient had new onset seizure activity with recent viral gastric symptoms. At the time he took report there were no lab results back yet, the patient’s VS were stable, and his seizure activity had improved with one dose of Ativan. There was no discussion of starting any additional seizure medications prior to transfer. Nothing from the initial report indicated the patient required a higher level of care or more stabilization. During an interview on 06/04/24 at 12:35, Staff JJ, Emergency Medical Technician (EMT), stated that when she and Staff II, Paramedic, arrived at Ozarks Healthcare the patient was unresponsive, limp, cool, and pale. His vitals looked better than how he appeared physically. Staff II did not initially object to the patient not being intubated. She stated that when they diverted to Hospital C, that facility did so much more for the patient. His airway was managed and he was put on more stabilizing medications after they obtained ROSC. She stated this was an inappropriate transfer because there were too many missing puzzle pieces. It should have been a specialty team transporting who had more pediatric capability. During an interview on 06/04/24 at 12:20 PM, Staff II, Paramedic, stated that when he assessed Patient #29 at Ozarks Healthcare prior to transport, the patient was unresponsive. The nurse said the patient had been posturing with a gaze fixed to the right and his seizure activity ceased after medication. He stated this patient seemed worse than a typical post-ictal seizure patient. The staff had placed the patient on supplemental oxygen, but offered to remove it for transport since he was not struggling to breathe. Staff II told them to leave it on and considered whether the patient ought to be intubated. However, he didn’t feel comfortable questioning the physician. The staff didn’t initially have lab results, then as they were about to leave, they learned his sodium was critically low. They started a normal saline infusion and gave some dextrose but did not discuss any additional stabilization measures. During an interview on 06/03/24 at 5:20 PM, Staff FF, Pediatric Intensivist, stated that he cared for Patient #29 in the PICU at Hospital D on 05/23/24 throughout the day. Staff FF thought it was likely that the patient had worsening of swelling in his brain in the ambulance which caused it to herniate (a serious medical condition that occurs when brain tissue shifts from one part of the brain to another due to increased pressure within the skull) and then caused the patient’s heart to stop. When asked if this could have been prevented, Staff FF stated that “It’s hard to know for sure, possibly with hypertonic saline or intubation.” The patient was intubated at Hospital C and given hypertonic saline; however, by the time he arrived at Hospital D the patient was already brain dead. When asked about the family, Staff FF stated that they appropriately sought medical care earlier in the week for vomiting and diarrhea and were trying to give oral fluids. Unfortunately, the patient decompensated quickly. They seemed generally clueless and responded late, but he did not have concerns for neglect. Review of Patient #16’s Ozark Healthcare medical record, dated 03/23/24, showed she was a 58-year-old female who presented to the ED at 3:51 PM with complaint of SOB with exertion over the past week. She was placed under the care of Staff G, ED Physician. She checked her oxygen saturation at home and it was normal. Her past medical history included high blood pressure. At 3:55 PM her vital signs showed BP at 124/85, Pulse was 71, Pulse Oximetry was 96 on room air. A CBC showed WBC was 11.55 (normal range was 3.29 - 11.43), Aspartate Aminotransferase (AST, an enzyme that is found mostly in the liver) was 38 (normal 0-32), Troponin was 15 (normal 0-10), Alanine Aminotransferase (ALT, high levels could indicate liver injury or disease) was 71 (normal 0-33), and Alkaline Phosphate (ALP, indicates liver disease or bone disorders) was 118 (35-105). A one view chest x-ray was done and showed no acute findings. An EKG showed low QRS (a measurement on an EKG tracing that measures the electrical impulse as it travels through the ventricles [lower chambers] of the heart) voltage present with no acute ST changes. The patient was given a home oxygen evaluation and had no hypoxia, no rapid heart rate or chest pain during the test. The patient was discharged and instructed to follow up with her primary care physician the following week. Review of the hospital’s untitled, undated grievance report regarding Patient #16 showed she was seen in the ED. Upon discharge from the ED, she had been unable to catch her breath and was not able to walk any distance. The following morning, she was taken to another hospital and was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for). She had fluid around her heart. The family stated the ED physician did not listen to her lungs or listen to the patient’s concerns. She was discharged with persistent shortness of breath. During an interview on 05/22/24 at 10:50 AM, Staff G, ED Physician, stated that the radiologist reviewed Patient #16’s chest x-ray and found no pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart), no cardiomegaly, and lungs were unremarkable. He reviewed the chest x-ray during the interview and stated there was “some effusion in the left lower lobe and her heart was slightly enlarged from that view” when he compared it to the previous chest x-ray. He stated that her troponin had been elevated but she did not complain of chest pain and her EKG was good, so he was not concerned. He stated that “her symptoms were unchanged” when she was discharged and she was instructed to follow-up with her primary care provider. He did not order a BNP. During an interview on 05/22/24 at 1:45 PM, Staff X, RN, stated that she did not see the physician go into Patient #16’s room. Patient #16 seemed very winded and had difficulty breathing especially with exertion, although she was evaluated by Respiratory Therapy (RT) and her oxygen level remained normal. She was discharged from the ED and her symptoms were unchanged. During an interview on 05/22/24 at 3:04 PM, Staff EE, Respiratory Therapist (RT), stated that she did a home oxygen evaluation on Patient #16. A home oxygen evaluation consisted of walking the patient for six minutes. Her oxygen saturation level remained normal during this evaluation. There was no other documentation that showed if Patient #16 was having shortness of breath during the evaluation. During an interview on 05/22/24 at 3:00 PM, Patient #16’s family member, stated that “she was discharged and could not walk across the room without having shortness of breath.” Patient #16 was taken to Hospital G for evaluation the following day, was admitted to ICU and had 1450 milliliters of fluid drained from her chest. She stated that she also had a heart attack. She was very unhappy with the care that her mother received and felt like they were rushed out of the ED while Patient #16 was still symptomatic. She stated the ED did “nothing to help my mom.” Although requested, Hospital G did not provide the medical record for Patient #16. Review of Patient #14’s first medical record from Ozarks Healthcare, dated 12/03/24, showed he was a 75-year-old male who presented to ED at 11:19 AM for complaints of shortness of breath and cough for three days. He had a past medical history of CHF, atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) and high blood pressure. Staff G, ED Physician, assumed care upon arrival to the ED. VS were obtained and his BP was 215/112, pulse was 54, temperature was 98.7, oxygen saturation was 94% on room air. A chest x-ray showed bilateral lower lobe densities and an EKG showed A-fib with slow ventricular response (ventricular rate less than 60). At 11:45 AM a CBC and CMP were done, and results were within normal limits. A Troponin baseline was completed that was 30 (normal was 0-15); At 1:48 PM a two-hour Troponin was repeated and was 26.68 (normal 0-15). Staff G documented that labs and imaging were reviewed. Patient #14 was given a prescription for Lasix (medication used to treat water retention, swelling, and high blood pressure) and discharged home with the clinical impression of CHF and A-fib. Review of Patient #14’s second medical record from Ozarks Healthcare, dated 12/04/24, showed he returned to the ED at 4:44 PM with increased confusion and agitation. Multiple people had to restrain him while he was intubated, due to the threat to himself and others. Staff N, ED Physician, assumed care upon arrival to the ED. Lab work was obtained and showed an ammonia level of 192 (normal 16-60) and the Troponin Baseline was 62 (normal was 0-15). Patient #14 was admitted into ICU with the diagnosis of altered mental status likely from hepatic encephalopathy (inflammation of the brain brought on by severe liver disease). Upon admission he was diagnosed with bilateral pulmonary embolism (PE, blood clot in the lung), elevated troponin, A-Fib, mixed respiratory and metabolic acidosis (condition where too much acid accumulates in the body and can be related to a buildup of body toxins or kidney failure) and embolic stroke (medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients). Review of the hospital’s untitled, undated document regarding the grievance of Patient #14 showed the family filed a complaint with the hospital. The family stated they were concerned about Patient #14’s ED visit on 12/03/23. The complainant stated that her father was seen and discharged home and then had to come back via EMS on 12/04/23. He was intubated and placed in ICU. She stated that her father was in critical condition with multiple PEs in the lungs. The review was sent to Staff Y, CMO, for a peer review. Although requested, the peer review regarding Patient #14 was not provided. During an interview on 5/22/24 at 10:50 AM, Staff G, ED Physician, stated that Patient #14 appeared to be in fluid overload in his opinion. He had no indication of having a PE. He did not order an ammonia level on him based on the symptoms he presented with on 12/03/24. He believed the elevated troponin was a result of the fluid overload. He felt confident in discharging the patient as stable. During an interview on 05/23/24 at 9:00 AM, Staff N, ED Physician, stated that Patient #14 presented to the ED on 12/04/24 with significant altered mental status. He stated the grievance was reviewed at peer review and by the CMO. “The patient had a history of alcohol abuse and many medical problems that all exacerbated at the time.” Review of Patient #25’s medical record from Ozarks Healthcare, dated 02/03/24, showed on he came to the ED complaining of right-sided shoulder pain radiating into his elbow. He denied any injury and thought he slept on it wrong. He had seen a chiropractor without any improvement. He had COVID (highly contagious, and sometimes fatal, virus) a few weeks before and reported some chills. His temperature was 99.3, his blood pressure was 173/97 and his other VS were normal. His pain was treated with two pain medications, a muscle relaxant and a steroid. His initial pain score was 9/10 and no pain reassessment was documented. An x-ray of the cervical (neck region of the back) spine was unremarkable and a respiratory pathogen panel was negative. He was diagnosed with cervical radiculopathy (compression and inflammation of any of the nerve roots of the cervical spine) and given prescriptions for pain medicine and steroids. At discharge his temperature was not rechecked and his blood pressure was 133/76. He was instructed to return for continued fever, worsening pain, swelling, or other concerning symptoms, and to follow up with his primary care provider. Review of Patient #25’s medical record from Ozark Healthcare, dated 02/05/24 showed he returned to the ED with persistent neck and right arm pain which he rated 10/10. The physician’s review of systems noted the patient denied fever or chills; however, he had a documented temperature of 100.6 upon arrival. A CT of the spine showed no acute findings. He was given pain medicine and improved per the physician, although a pain reassessment was not documented. An EKG was unremarkable. Staff G, ED Physician, documented a discharge diagnosis of cervical radiculopathy with a plan to discharge home on a higher dose of steroids, another muscle relaxant, and arrangements for an outpatient Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) and orthopedic (medical specialty dealing with bones) spine surgery follow-up. Review of Patient #25’s outpatient medical record showed on 02/07/24 an MRI was performed and an abscess (collection or pocket of thick fluid caused by an infection) was found in the epidural (the outer space around the spinal cord) space, abnormal appearance of the soft tissues around the mid to lower cervical spine, moderate disc protrusion, and marrow (mix of cellular elements enclosed within bone) edema in the spine that was suspicious for osteomyelitis (infection of the bone). Additional imaging with contrast was recommended. The patient had not had any further fevers since 02/05/24; he did not take the prescribed steroids due to his primary care provider’s recommendation, so as not to worsen his blood sugar; and reported the pain medicine did not help. A chronic diabetic ulcer (an open wound or sore usually found on the bottom of feet in people with diabetes) was noted to his left great toe with skin breakdown. When the MRI results were called to the patient, he notified the provider that he would seek further treatment at Hospital B. Review of Patient #25’s medical record from Hospital B, dated 02/07/24, showed he presented to the ED complaining of neck pain. His work-up from Ozarks Healthcare clinic showed an elevated WBC, an MRI concerning for an epidural abscess, and a diabetic wound on his foot that had a history of osteomyelitis. In the ED the patient had normal VS with moderate high blood pressure. He appeared uncomfortable but was not acutely distressed. His bloodwork showed an elevated WBC, slightly elevated inflammatory markers, a normal lactic acid and some kidney dysfunction. A chest x-ray was unremarkable, and a repeat MRI showed fluid collection causing some anterior canal narrowing, diffuse enhancement of the cauda equina (the sack of nerve roots at the lower end of the spinal cord) without mass effect, and abnormal paraspinal and epidural enhancement. The neurosurgery (a branch of medicine or surgery performed on the nervous system, especially the brain and spinal cord) consult recommended admission and antibiotics to prevent spinal epidural abscess. Surgery was performed on 02/08/24 for a posterior cervical fusion. He was treated in the neurotrauma ICU (an intensive care unit devoted to the care of patients with immediately life-threatening nervous system problems) after surgery and was intubated until 02/09/24. He remained in the hospital to manage his blood pressure, blood sugars, and an ileus (intolerance of oral intake due to inhibition of the GI propulsion without signs of mechanical obstruction) that developed. He was discharged on 02/21/24 with home health care to manage ongoing antibiotic infusions. Review of the hospital’s untitled, undated document regarding the grievance of Patient #25 showed on 02/03/24 the patient was treated for cervical radiculitis with a temp of 99.3. No bloodwork was done and the pain medicine did not improve his symptoms. The patient contacted his daughter-in-law, who was a Licensed Practical Nurse (LPN) at the outpatient clinic, and told her his symptoms were worse. She recommended he go back to the ED. On 02/05/24 he was seen again in the ED where a CT was done without significant findings. Although the patient had a fever of 100.6, no bloodwork was done. The patient reported he did not get an IV because they couldn’t find a vein. The plan of care was to get an MRI and follow up with a specialist. The patient called his daughter-in-law again after discharge reporting he was still in significant pain. She spoke with his primary care physician who ordered bloodwork the next day, had him stop the steroids due to no improvement and ordered prophylactic (to prevent disease or deterioration) antibiotics. The lab work showed an elevated WBC, blood sugar, and inflammatory markers. The patient got an MRI that day which showed an epidural abscess. The family reported he was admitted to the neurotrauma ICU of Hospital B for sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs), surgery, and was on a ventilator (a machine that supports breathing). The complainant reported discrepancies in the ED chart including failure to note the patient’s foot ulcer, documenting no fevers when fever was present, documenting no numbness or tingling, and failure to note the right-sided grip weakness. After review of the grievance, Staff G, ED Physician, felt the work-up was appropriate with the information given. During an interview on 05/22/24 at 10:50 AM, Staff G, ED Physician, stated that Patient #25 was seen a couple of days before and had a negative respiratory pathogen panel. He believed the patient’s low-grade temperature was related to his respiratory symptoms and thought he had likely coughed or sneezed and messed up a disc. He arranged for the patient to get the first possible outpatient MRI appointment because an MRI was not available in the ED. An epidural abscess would not be seen on a CT unless it was with contrast; however, the radiologists preferred an MRI. He did not consider labs at the time due to the upper respiratory infection (URI, irritation and swelling of the upper airways with associated cough and nasal congestion) symptoms. During an interview on 05/23/22 at 10:50 AM, Staff CC, ED Physician, stated that she cared for Patient #25 in the ED at Hospital B. She did not remember the patient but was able to review the chart. His vital signs were not concerning for acute sepsis in the ED and the patient did not seem distressed, although he was uncomfortable. Their protocol called for aggressive management of suspected infection with antibiotics; but this patient did not become tachycardic, febrile, or hypotensive which would have indicated sepsis. She stated the spinal diagnosis was frequently missed and was hard to diagnose. It was not a routine surgery, necessarily, but if left untreated it could affect everything in the spine below the level that was abscessed. During an interview on 05/22/24 at 2:15 PM, Staff J, RN, stated that she was unable to remember Patient #25. She reviewed the chart and her nursing assessment. She noted his pain score was 10/10 and he received pain medication but was unable to find a pain reassessment. She stated the doctors were very good about assessing and stabilizing patients and they would talk to patients again if they still had questions about their discharge plan. During an interview on 05/23/24 at 8:25 AM, Staff BB, ED RN, stated that she was a travel RN in the ED for over two years and was no longer contracted at Ozarks Healthcare. She could not remember Patient #25 or Patient #13, specifically, and could not review their charts since she was no longer employed with the hospital. She stated the work culture at Ozarks Healthcare “seemed more lax” than other places she worked. She stated the co-medical directors (Staff G and Staff N) were the two physicians most likely to not assess their patients thoroughly unless you knew them personally. She never saw one of the physicians assess the patient from the doorway or not assess them at all, but the assessments were often short and limited. She described the volume of patients as tolerable and not overwhelming. 49489”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47504 Based on interview, record review, and policy review, the hospital failed to ensure that emergency medical conditions (EMC) were stabilized for six patients (#4, #14, #16 #25, #28, and #29) out of 29 Emergency Department (ED) sample cases reviewed from 11/24/23 through 05/23/24, when they were discharged or transferred with unstable medical conditions. Findings included: Review of the hospital’s policy titled “Physician Responsibilities in the ED,” dated 08/2021, showed the primary responsibility of the ED physician was the prompt care of patients who presented to the ED and inpatients declared to have a life-threatening emergency. The ED physician would perform medical and surgical procedures within their capacity necessary to prevent death or prolonged disability or injury. All patients leaving the ED would be given instructions for further care including the follow-up physician or a list of physicians they could contact for primary care services. Review of the hospital’s policy titled “Medical Screening in the ED,” dated 10/2020, showed all patients who presented to the ED and requested examination or treatment would receive an appropriate medical screening exam (MSE). All patients who presented with an EMC would receive necessary stabilizing treatment or appropriate transfer. EMCs would include any condition with acute symptoms of sufficient severity such that the absence of immediate medical attention would reasonably be expected to result in placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. The MSE would consist of a face-to-face evaluation by the physician or mid-level provider; completion of any diagnostic tests necessary to rule out an EMC; completion of the electronic health record; and appropriate discharge and referral instructions. Review of the hospital’s policy titled “Pain Management,” dated 08/2022, showed patients in the ED would be screened and treated, or referred for treatment of pain, following an MSE. Pain was described as mild, moderate, or severe, and measured using a self-reported pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and ten means worst pain possible). Reassessment of pain was documented one hour after an intervention and when appropriate such as a change in the patient’s condition. All newly hired staff were required to complete competency training during the orientation period. Review of the hospital’s policy titled “ED Radiologic Discrepancies,” dated 10/2021, showed a combination of Ozarks Healthcare radiologists and virtual radiologists would read all radiologic studies. ED providers would complete an initial impression of their interpretation of plain film radiology studies. The radiologist would review all initial interpretations and document “agree” or “disagree” and record the final interpretation of the study. The radiologist would attempt to contact the ED physician immediately in cases of major discrepancies. When a change in treatment was needed, the ED manager or a charge nurse would contact the patient about necessary changes to their treatment plan. Review of the ambulance report for Patient #4, dated 12/29/23, showed Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived at her home at 9:18 AM. She reported a large amount of blood in her stool and denied pain, nausea or vomiting. Her abdomen was soft and non-tender. She had a history of gastrointestinal (GI) bleeds and hernias (when part of the intestine bulges through the opening of abdominal muscles). The cardiac monitor (noninvasive monitor of the heart that attach to the patient’s chest and record heart rhythm) showed her heart rate was elevated between 113 and 133. Her vital signs (VS, measurements of the body’s most basic functions. Blood pressure (BP normal between 90/60 and 12/80; pulse/heartbeats normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature normal 97.8 to 99 degrees) were otherwise stable. An intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) was placed and she was given fluids. EMS transported Patient #4 to Ozarks Healthcare and gave report to Staff L, ED Charge Nurse. Review of Patient #4’s medical record from Ozarks Healthcare, dated 12/29/23, showed she arrived in the ED by ambulance at 10:42 AM. She had a past medical history of chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing). She complained of a distended abdomen ongoing for months and multiple bloody bowel movements that day. She reported she had previous exams and CTs for this issue in the past without resolution. She told the triage (process of determining the priority of a patient’s treatment based on the severity of their condition) nurse she bled “gallons of blood” while using the toilet that morning. Her assessment by Staff AA, ED Physician, showed normal bowel sounds and her abdomen was soft to palpation, non-tender, and nondistended. A computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) report of her abdomen and pelvis showed there were no acute abnormalities, no site or cause of GI bleeding. Urine and blood work showed an elevated white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood), a normal hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body), and a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). She was given IV fluids and started on an antibiotic. The discharge diagnoses were hematochezia (bright red blood in the stools) and UTI, and her condition was listed as stable. Her discharge VS showed she had no fever, her heart rate was 115, her oxygen saturation was 91%, and her blood pressure was normal. She was instructed to take the antibiotics, drink oral fluids, follow up with her primary care physician and consider seeing a GI specialist for a colonoscopy (a procedure to examine the interior of the colon with a lighted tube with a camera). On 12/30/23 Staff G, ED Physician, documented that a quality review found unreported findings in the patient’s CT. There were signs of a clot in the superior mesenteric artery (SMA, provides oxygenated blood and nutrient to the intestines) with possible bowel ischemia (restriction in blood supply to tissues, causing a shortage of oxygen needed to keep tissue alive) and a right renal (pertaining to the kidneys) infarct (tissue death due to inadequate blood supply to the affected area). The patient was notified and instructed to seek immediate medical care. After multiple attempts, the staff confirmed the patient would seek care at Hospital D and Staff G made sure that facility was aware of the patient and provided them with her relevant medical records. Review of Patient #4’s medical record from Hospital D, dated 12/30/23, showed she complained of bloody stools and burning abdominal pain. She reported that Ozarks Healthcare performed a CT and found an ischemic bowel. She was noted to be chronically ill-appearing, her pain was well-controlled, and her VS were stable. A repeat CT of the abdomen and pelvis showed a complete occlusion of the superior mesenteric artery (SMA, provides oxygenated blood and nutrient to the intestines) and partial kidney infarct (tissue death due to inadequate blood supply to the affected area). She was taken to the operating room on 12/30/23 by the vascular surgeon for exploratory laparotomy (a surgical incision into the abdominal cavity) with SMA embolectomy (removal of a blood clot) and placement of negative pressure wound vacuum assisted closure (wound VAC, a device that decreases air pressure on a wound to help it heal more quickly). She was discharged on 01/08/24 with a wound VAC in place. Review of the hospital’s untitled, undated grievance report regarding Patient #4 showed the patient complained that she was misdiagnosed by Staff AA, ED Physician. A staff member called her the day after she was treated and told her the radiologist mistakenly read one of her old CT scans. The conversation documented with the patient included several complaints. She brought up mishandling of her daughter a few years prior, she stated she lost 24 pounds of blood overnight, a staff member in the waiting room was dismissive of her bleeding and asked her why she was being hostile, she reported becoming septic (life threatening condition when the body’s response to infection injures its own tissues and organs) after being discharged, she was upset about a specialist referral she had from a separate visit, and the patient was also concerned about the dates being noted correctly in the grievance. The report concluded that Staff AA, ED Physician, was not given the correct radiology results to make an accurate diagnosis. During an interview on 05/22/24 at 10:50 AM, Staff G, ED Physician, stated that the medical director of the contracted radiology service called him and reported their quality assurance program spotted a discrepancy in Patient #4’s CT report. Staff G had the charge nurse call the patient multiple times to urge her to seek medical care. Once the patient said she would go to Hospital D, he contacted their staff to notify them the patient was coming and arranged for her scans to be available to them. When asked if this was a common occurrence; he stated that the radiology service would call occasionally to report a discrepancy found on quality checks, but rarely an error this significant. This was not the kind of error an ED physician could find looking at the scan themselves. He discussed other differential diagnoses for rectal bleeding with a normal CT scan such as bleeding diverticuli (when pockets form in the walls of the colon) or pneumatosis (the presence of gas within the wall of the small or large intestine). He stated that if the patient had a normal hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body) he would start antibiotics and refer to primary care to discuss an outpatient colonoscopy. During an interview on 05/22/24 at 5:50 PM, Staff AA, ED Physician, stated that he did not remember Patient #4. He could not think of any other examples of radiology issues similar to her CT being misread. When asked about the patient’s condition at discharge, he was unable to find a reassessment in the chart or update on her symptoms. He stated that if he had been given the correct CT results, he would have arranged transfer to a higher level of care. During an interview on 06/04/24 at 10:30 AM, Staff HH, ED Physician, confirmed that she cared for Patient #4 in the ED at Hospital D. She recalled the patient was upset and confused about her CT being misread at the previous hospital. She did not appear acutely unstable at the time and her symptoms were intermittent. Staff HH stated that diagnosing an ischemic bowel was entirely dependent on an accurate radiology report. Symptoms such as rectal bleeding and abnormal labs such as an elevated lactic acid (an acid produced in muscle tissues during strenuous exercise) or low hemoglobin could point toward the problem, but those signs could be explained by lots of different conditions. During an interview on 05/22/24 at 12:45 PM, Staff L, ED Charge Nurse, stated that she was unable to remember Patient #4. She reviewed the chart and noted the heart rate seemed a little elevated but nothing else was especially concerning. She stated that if a patient wanted to be seen again after discharge, the staff all knew they should sign them back in to start the assessment process over again. She stated that Staff AA, ED Physician, was very thorough in his physical exams and he was one of her favorites to work with. During an interview on 06/03/24 at 4:00 PM, Staff GG, RN, stated that she was unable to remember Patient #4. She thought it was unlikely that if the patient had requested to be seen again the ED, staff would have refused. She stated they frequently had patients sign back in after discharge. During an interview on 06/04/24 at 12:50 PM, Staff KK, Registration Coordinator, stated that she did not remember Patient #4 showing waiting room staff pictures of her bloody bowel movement on 12/29/23 or requesting to check back into the ED. She stated that patients frequently asked to be seen again after discharge because their symptoms worsened, and all the registrars knew to sign them back in if they requested further care. During an interview on 05/20/24 at 1:55 PM, Staff E, ED Registrar, stated that if a patient had been discharged and wanted to be seen again, they would immediately register them again and start a new encounter. During an interview on 05/20/24 at 2:00 PM, Staff F, ED Charge Nurse, stated that if a patient was discharged and wanted further evaluation, the expectation was that staff would check them back in. The physicians would all be willing to see them again. During an interview on 05/22/24 at 9:40 AM, Staff M, ED Physician, stated that he did not have any concerns with the quality of the radiology reports. He often worked at other hospitals and did not think there was any difference in the reliability of the reports, although there were sometimes frustrating delays. During an interview on 05/22/24 at 9:45 AM, Staff N, ED Medical Director, stated that the contracted radiology service was not always reliable for good turnaround times. They might wait three hours overnight for a read. He stated there had recently been some notable “misses” in the reports. The ED physicians sometimes had to call the radiologist to clarify reports or point out concerns. Review of Patient #28’s medical record, dated 12/14/23, showed he was a 54-year-old male who presented to the ED at 6:41 AM via EMS with complaints of shortness of breath (SOB) and chest discomfort. The chest pain was on the left side of the chest and radiated down the left arm. Staff G, ED Physician, assumed care of the patient. Patient #28 had been given an aspirin (blood thinner that can also treat pain, fever, headache and inflammation) 325 mg by mouth and 3 nitroglycerin (medication used to prevent chest pain caused by heart disease) tablets prior to arrival to the ED. His past medical history included end stage renal disease (ESRD, the final stage of kidney disease, where the kidneys can no longer function on their own) with hemodialysis (dialysis, process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions), congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues), and coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries) with stent placement (a tiny tube placed into an artery, a vein or another structure to hold the structure open). He used home oxygen at three liters via nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen). At 6:43 AM VS showed his BP 188/89, Pulse 77, RR 16, and oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 95%. At 6:50 AM a chest pain assessment was done and was identified as a moderate constant pain that started in the left chest and radiated down to the left arm. He rated the pain 5/10. A complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) were done and results were within normal limits. Severe acute respiratory syndrome (SARS, a rapidly spreading, potentially fatal infectious viral disease) swab was negative. At 6:58 AM a troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.001) baseline was obtained and was 71 (normal was 0-15). At 7:23 AM, VS showed BP was 188/109, pulse was 77, Respirations was 34, and oxygen saturation was 95%. At 8:51 AM, a two-hour troponin was obtained and was 80.77. An EKG was done that showed sinus rhythm (normal heart rate), possible left atrial enlargement (the left side of the heart is enlarged), possible myocardial infarction (MI, heart attack), of indeterminate age. Chest x-ray showed minimal cardiomegaly (enlarged heart). He was given hydralazine (a medication used to treat high blood pressure) 10 mg at 7:41 AM, Tylenol (a medication that treats minor pains and fever) 650 mg PO at 8:46 AM, Ativan (a medication used to treat anxiety or sleep difficulty) 2 mg IV at 8:47 am, and Labetalol (medication used to treat high blood pressure) 10 mg at 9:09 AM. At 9:11 AM his pain was rated 6/10 and was reassessed at 9:29 AM when he rated his pain 3/10. Staff G documented upon discharge that cardiac enzymes (proteins that enter the bloodstream when there has been damage to the heart muscle) were within normal range, there was a slight increase in his troponin but he was no longer having chest discomfort. An angiogram (a scan that shows blood flow through arteries or veins, or through the heart) was done a year and a half ago that did not show critical disease. He suspected the troponin was elevated due to fluid overload and his chronic kidney disease. He was asymptomatic and was discharged from the ED to dialysis at 9:29 AM. Review of Patient #28’s medical record from Facility F showed on 12/14/23 he presented for hemodialysis following discharge from the ED. He was very weak, came in a wheelchair, and was shaky. He complained of SOB and continued chest pain that radiated to his left shoulder and arm. He rated his chest pain 6 out of 10 on a pain scale. Hemodialysis began at 11:26 AM and was discontinued at 1:11 PM per patient request. Patient #28 called a family member to come and take him to another hospital for his increasing chest pain. Review Patient #28’s medical record from Hospital J, dated 12/14/23, showed he presented with chest pain and SOB. He stated that he had been seen at Ozarks Healthcare and was told to go to dialysis and he would feel better. He did go to dialysis and continued to have chest pain. His EKG did not show any acute changes, troponin was 74, proBNP (measures the levels of a hormone in your blood, high levels of BNP can be a sign of heart failure. Normal range should be lower than 450) was 4000. Due to the patient’s extensive cardiac history, he was transported to the ED at Hospital D for further evaluation. Review of Patient #28’s medical record from Hospital D, dated 12/14/23, showed he arrived and was admitted for a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions). Review of the hospital’s untitled, undated grievance report regarding Patient #28 showed he was seen and discharged from the ED to dialysis. He was undergoing dialysis for approximately one hour when he became unstable and was sent by EMS to Hospital J. He was stabilized, sent to Hospital D and underwent angioplasty (a procedure to repair or unblock a blood vessel) with two stents placed. The family was unhappy about the quality of care that he received from Staff G, ED Physician. Staff G reviewed the grievance and stated that he thought the elevated troponin was from the patient’s renal failure and mild CHF. Patient #28 was due for dialysis that morning and had no acute EKG changes. During an interview on 06/04/24 at 2:00 PM, Staff G, ED Physician, stated that he felt Patient #28 was in fluid overload and needed to go to his dialysis appointment. He was aware of the troponin being elevated but felt it was from his chronic kidney disease. He had reviewed his medical history and stated the patient had an angiogram approximately one and half years ago and it showed no chronic disease. He stated that he was made aware that the patient had a code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly responds to attempt to restore the heartbeat or breathing) during dialysis later that morning and was transported via EMS to another hospital. He stated that Patient #28 ended up having stents placed at Hospital D. During an interview on 06/11/24 at 12:45 PM, Staff PP, Clinic Manager from Facility F, stated that on 12/14/23 she evaluated Patient #28, he had been seen at the ED and was discharged with the diagnosis of fluid overload. He presented in a wheelchair and normally he ambulated into their clinic with use of a walker. During hemodialysis, he kept complaining of increased chest pain and it was discontinued. He declined to have an emergency transport as they would take him to the nearest hospital which was Ozarks Healthcare. He did not want to go back to that hospital. He left with a family member and went to Hospital J to be evaluated. During an interview on 06/10/24 at 2:30 PM, Staff OO, Secretary from Facility F, stated that their facility will not send their patients to Ozarks Healthcare in emergency situations. She stated they have multiple patients that have been seen at the ED at Ozarks Healthcare and discharged; then go to another facility and were admitted for a serious situation. Review of Patient #29’s medical record from Ozarks Healthcare, dated 05/23/24, showed the patient was a 21-month-old male who arrived in the ED at 12:32 AM with a chief complaint of altered mental status (mental functioning ranging from slight confusion to coma). His grandparents reported he started vomiting on 05/20/24. He was seen as an outpatient on 05/21/24, diagnosed with a GI bug and sent home. During the evening of 05/22/24, he had decreased responsiveness and seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness)-like activity. He took no medications and there was no known trauma or ingestion of toxins. He was unresponsive to painful stimuli, had stiffened posture and his gaze was deviated toward the upper right. His pupils were pinpoint, equal, round, and reactive to light. He had no meningeal signs (nonspecific reactions that may occur in a patient with meningeal irritation). The staff administered Ativan, IV fluids and dextrose (sugar). The lab results showed a critically low sodium (a type of electrolyte in the blood, normal range 135-145) of 116, high potassium 5.7 (normal range 3.5-5), critically high creatine kinase (an enzyme found in the brain, skeletal muscles and the heart, an elevated level could be associated with damage to those areas, normal range 22-198) of 1,957, and blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health. Normal ranges are considered between 70 and 100) of 69. A respiratory pathogen panel later showed the patient had adenovirus and parainfluenza (family of viruses that can cause infections in the respiratory tract). His chest x-ray showed findings that could be seen in viral conditions versus reactive airway disease. Hospital D accepted transfer of the patient to the general pediatric floor. He was originally to be transferred by air, however, weather prevented air transport and EMS was dispatched. Review of the ambulance record for Patient #29 between Ozarks Health and Hospital D showed they left the hospital on 05/23/24 at 1:55 AM. The patient was saturating well on 1L of oxygen initially. The cardiac monitor showed a normal heart rhythm. His VS abruptly changed around 2:10 AM and Staff II, Paramedic, removed the patient from his car seat, started bagging (providing positive pressure ventilation to patients who are not breathing or not breathing adequately) and gave chest compressions. Five doses of epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) were administered during the event. After the second loss of pulses, Staff II decided to divert to Hospital C for assistance. The patient had a return of spontaneous circulation (ROSC) upon arrival to Hospital C at 2:40 AM. Review of Patient #29’s medical record from Hospital C, dated 05/23/24, showed the patient arrived at 2:41 AM. He was immediately triaged (process of determining the priority of a patient’s treatment based on the severity of their condition) and seen by a provider. He was ventilated with a laryngeal mask airway (LMA, a supraglottic airway device that may be used as a temporary method to maintain an open airway) after endotracheal intubation (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) was unsuccessful. He had additional bloodwork and a chest x-ray. The physician reported the patient’s problems included cardiac arrest (when the heart suddenly and unexpectedly stops pumping), acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), aspiration pneumonia (infection in the lungs caused by food or liquid entering the lungs instead of being swallowed), low blood pressure, low blood sugar, severe dehydration (a condition caused by excessive loss of water from the body), severely low sodium, and hypoxia (not enough oxygen reaching the cells and tissues in the body). He had a low core temperature of 90.0, fixed pupils, and abnormal heart rhythms. He was shocked with a defibrillator (a device that controls the heart beat by applying an electric current to the chest wall or heart) three times. He was given IV antibiotics, hypertonic saline (a crystalloid intravenous fluid with a higher sodium concentration than normal blood serum, used in critical care to treat hyponatremia, severe dehydration, and brain injury), IV fluids, IV dextrose and calcium chloride (an inorganic salt compound). Once stabilized, he was transferred by ambulance to the Pediatric Intensive Care Unit (PICU, unit for ill children) at Hospital D at 3:44 AM. Air transport was declined by three helicopter services due to weather. Review of the Patient #29’s ambulance report from Hospital C to Hospital D showed he was unresponsive with an LMA, an orogastric tube (small tubes placed through the mouth and end with the tip in the stomach) and IVs in place. He had antibiotics, IV fluids, and dopamine (a peripheral vasostimulant) infusing. He remained stable during transport, although he had persistent low blood pressure. Report was given to the staff at Hospital D at 4:58 AM. Review of Patient #29’s medical record from Hospital D, dated 05/23/24, showed he arrived at 4:59 AM. An arterial line (thin, flexible tube placed into an artery) and central venous access (long, thin, flexible tube placed in a large vein and the end of the tube sits in a large blood vessel near to or in part of their heart, allowing multiple fluids to be given and blood to be drawn) were placed by Staff FF, Pediatric Intensivist. His LMA was replaced with an endotracheal tube (ETT, a tube inserted through the mouth or nose, that extends into the lungs, to maintain an open passageway for oxygen), a rewarming machine was utilized, and he was given IV vasopressors (a group of medicines that narrow blood vessels and raise blood pressure). He had no brain activity as assessed by electroencephalography (EEG, a recording of brain activity, often used to evaluate presence of seizure activity), and absent neurological reflexes (a sudden, instinctive and involuntary reaction to stimulation). The patient’s heart stopped at 9:15 PM and resuscitation was attempted for a while. He was pronounced dead at 9:35 PM due to worsening swelling and brain death. During an interview on 06/05/24 at 8:30 PM, Staff LL, RN, stated that she was working as the triage nurse when Patient #29 was brought in by grandparents. She saw that the child was unresponsive and immediately grabbed the patient and took him back to the trauma room. She stated that the ED physician and staff took over care. She stated that the grandparents seemed to be unaware of how serious the situation was. During an interview on 06/03/24 at 4:00 PM, Staff GG, RN, stated that she was one of the nurses who cared for Patient #29 at Ozarks Healthcare. She stated that when the grandparents arrived with the patient, a triage nurse noticed immediately that he seemed unresponsive and brought him directly to a room for treatment. The family reported he had vomiting and diarrhea for three to four days and started having episodes of unresponsiveness and grinding his teeth the day before. He was persistently unresponsive to IV needles and a urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) insertion. He started to have seizure-like activity and they administered Ativan and IV fluids. The seizure activity stopped after the medication and the patient seemed post-ictal (pertaining to the period after a seizure). Staff AA, ED Physician, arranged for the patient to be transferred to Hospital D. Staff GG recalled that when she called report to Hospital D, the lab results were not back yet. They learned about the critically low sodium level, “as they were rolling out to the ambulance.” Hypertonic saline was not available at the hospital, so they kept a normal saline solution infusing during transport. She was unaware if Staff AA had discussed starting an infusion of stronger seizure medications with the accepting doctor. At the time of transport, the patient was supporting his own airway well with normal VS and intubation was not considered necessary. The amount of time the patient was treated at Ozarks Health was about one hour. When asked about the family, Staff GG stated that “they did not seem anxious. They were non-medical and had no idea how sick he was.” She understood the patient and his siblings were being cared for back and forth by the grandparents and great-grandparents while the parents were on vacation, and there was likely some miscommunication about his condition. One of the caregivers had called the ED earlier in the evening to ask for advice and a nurse had recommended they bring him in to be evaluated, but it was more than three hours before they brought him in. During an interview on 06/04/24 at 10:30 PM, Staff MM, RN, stated that Patient #29 was floppy when he first arrived, but then his body stiffened up and he began to clench his teeth. They gave a dose of Ativan, checked his blood sugar, gave him IV fluids and dextrose. The family was oddly calm and seemed unaware of the emergent situation. The ED worked as a team, but the patient clearly needed pediatric specialists. The patient was on the EMS stretcher when lab started calling with critical labs. “This was a very sick child and we did all we could to stabilize him.” During an interview on 06/10/24 at 5:45 PM, Staff AA, ED Physician, stated that Patient #29 arrived and was brought back by the triage nurse immediately. He stated that the patient was unresponsive and his body was limp and would then get stiff, as if he was having a seizure. He ordered a dose of Ativan to be given for the seizure activity. He stated the nurses obtained IV access and attempted to get a urinalysis (a laboratory examination of a person’s urine) but when the nurse attempted, she was unable to get a urine sample. He stated that he immediately called Hospital D to arrange for a transfer. They attempted to call for air transport but were denied due to weather conditions. He stated they then called for an ambulance to transport the patient. At the time of discharge the patient had been stabilized as best as he could. He stated that as the patient was being wheeled out to the ambulance, they received critical lab results and he called Hospital D to let them know the results. During an interview on 06/05/24 at 10:20 AM, Staff NN, Pediatric Hospitalist from Hospital D, stated that he accepted Patient #29 for transfer to the general pediatric floor at Hospital D. The report he received from Staff AA, ED Physician, was that the patient had new onset seizure activity with recent viral gastric symptoms. At the time he took report there were no lab results back yet, the patient’s VS were stable, and his seizure activity had improved with one dose of Ativan. There was no discussion of starting any additional seizure medications prior to transfer. Nothing from the initial report indicated the patient required a higher level of care or more stabilization. During an interview on 06/04/24 at 12:35, Staff JJ, Emergency Medical Technician (EMT), stated that when she and Staff II, Paramedic, arrived at Ozarks Healthcare the patient was unresponsive, limp, cool, and pale. His vitals looked better than how he appeared physically. Staff II did not initially object to the patient not being intubated. She stated that when they diverted to Hospital C, that facility did so much more for the patient. His airway was managed and he was put on more stabilizing medications after they obtained ROSC. She stated this was an inappropriate transfer because there were too many missing puzzle pieces. It should have been a specialty team transporting who had more pediatric capability. During an interview on 06/04/24 at 12:20 PM, Staff II, Paramedic, stated that when he assessed Patient #29 at Ozarks Healthcare prior to transport, the patient was unresponsive. The nurse said the patient had been posturing with a gaze fixed to the right and his seizure activity ceased after medication. He stated this patient seemed worse than a typical post-ictal seizure patient. The staff had placed the patient on supplemental oxygen, but offered to remove it for transport since he was not struggling to breathe. Staff II told them to leave it on and considered whether the patient ought to be intubated. However, he didn’t feel comfortable questioning the physician. The staff didn’t initially have lab results, then as they were about to leave they learned his sodium was critically low. They started a normal saline infusion and gave some dextrose but did not discuss any additional stabilization measures. During an interview on 06/03/24 at 5:20 PM, Staff FF, Pediatric Intensivist, stated that he cared for Patient #29 in the PICU at Hospital D on 05/23/24 throughout the day. Staff FF thought it was likely that the patient had worsening of swelling in his brain in the ambulance which caused it to herniate (a serious medical condition that occurs when brain tissue shifts from one part of the brain to another due to increased pressure within the skull), which then caused the patient’s heart to stop. When asked if this could have been prevented, Staff FF stated that “It’s hard to know for sure, possibly with hypertonic saline or intubation.” The patient was intubated at Hospital C and given hypertonic saline; however, by the time he arrived at Hospital D the patient was already brain dead. When asked about the family, Staff FF stated that they appropriately sought medical care earlier in the week for vomiting and diarrhea and were trying to give oral fluids. Unfortunately, the patient decompensated quickly. They seemed generally clueless and responded late, but he did not have concerns for neglect. Review of Patient #16’s medical record, dated 03/23/24, showed she was a 58-year-old female who presented to the ED at 3:51 PM with complaint of SOB under the care of Staff G, ED Physician. She complained of SOB with exertion over the past week. She checked her oxygen saturation at home and it had been normal. Her past medical history included high blood pressure. At 3:55 PM her vital signs showed BP at 124/85, Pulse was 71, Pulse Oximetry was 96 on room air. A CBC showed WBC was 11.55 (normal range was 3.29 - 11.43), Aspartate Aminotransferase (AST, an enzyme that is found mostly in the liver) was 38 (normal 0-32), Troponin was 15 (normal 0-10), Alanine Aminotransferase (ALT, high levels could indicate liver injury or disease) was 71 (normal 0-33), and Alkaline Phosphate (ALP, indicates liver disease or bone disorders) was 118 (35-105). A one view chest x-ray was done and showed no acute findings. An EKG showed low QRS (a measurement on an EKG tracing that measures the electrical impulse as it travels through the ventricles [lower chambers] of the heart) voltage present with no acute ST changes. The patient was given a home oxygen evaluation and had no hypoxia, no rapid heart rate or chest pain during the test. The patient was discharged and instructed to follow up with her primary care physician the following week. Review of the hospital’s untitled, undated grievance report regarding Patient #16 showed she was unable to catch her breath and not able to walk any distance. She was taken to another hospital the following morning and was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for). She had fluid around her heart. The family stated the physician did not listen to her lungs or listen to the patient’s concerns. She was discharged with persistent shortness of breath. During an interview on 05/22/24 at 10:50 AM, Staff G, ED Physician, stated that the radiologist reviewed Patient #16’s chest x-ray and found no pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart), no cardiomegaly, and lungs were unremarkable. He reviewed the chest x-ray during the interview and stated there was “some effusion in the left lower lobe and her heart was slightly enlarged from that view” when he compared it to the previous chest x-ray. He stated that her troponin had been elevated but she did not complain of chest pain and her EKG was good, so he was not concerned. He stated that “her symptoms were unchanged” when she was discharged and she was instructed to follow-up with her primary care provider. He did not order a BNP. During an interview on 05/22/24 at 1:45 PM, Staff X, RN, stated that she did not see the physician go into Patient #16’s room. Patient #16 seemed very winded and had difficulty breathing especially with exertion, although she was evaluated by Respiratory Therapy (RT) and her oxygen level remained normal. She was discharged from the ED and her symptoms were unchanged. During an interview on 05/22/24 at 3:04 PM, Staff EE, Respiratory Therapist, stated that she did a home oxygen evaluation on Patient #16. A home oxygen evaluation consisted of walking the patient for six minutes. Her oxygen saturation level remained normal during this evaluation. There was no other documentation that showed if Patient #16 was having shortness of breath during the evaluation. During an interview on 05/22/24 at 3:00 PM, Patient #16’s family member, stated that “she was discharged and could not walk across the room without having shortness of breath.” She was taken to Hospital G for evaluation the following day, was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) and had 1450 milliliters of fluid drained from her chest. She stated that she also had a heart attack. She was very unhappy with the care that her mother received and felt like they were rushed out of the ED while Patient #16 was still symptomatic. She stated the ED did “nothing to help my mom.” Although requested, Hospital G did not provide the medical record for Patient #16. Review of Patient #14’s first medical record, dated 12/03/23, showed he was a 75-year-old male who presented to ED at 11:19 AM for complaints of SOB and cough for three days. A chest x-ray showed bilateral lower lobe densities and an EKG showed atrial fibrillation (A fib, an irregular, often rapid heart rate that commonly causes poor blood flow) with slow ventricular response (ventricular rate less than 60). A baseline Troponin was 30 (normal was 0-15); a two hour repeat Troponin was 26.68 (normal 0-15). Staff G, ED Physician, documented that labs and imaging were reviewed. He was given a prescription for Lasix (medication used to treat water retention, swelling, and high blood pressure) and discharged home with the clinical impression of CHF and A fib. Review of Patient #14’s second medical record, dated 12/04/23 at 4:44 PM, showed he returned to the ED with increased confusion and agitation. Due to the threat to himself and others, multiple people had to restrain him as he was intubated. Staff N, ED physician assumed care upon arrival to the ED. Lab work was obtained and showed an Ammonia level of 192 (normal 16-60) and Troponin Baseline was 62 (normal was 0-15). Patient #14 was admitted to the ICU with a diagnosis of altered mental status likely from hepatic encephalopathy (inflammation of the brain brought on by severe liver disease). Upon admission he was diagnosed with bilateral pulmonary embolisms (PE, blood clot in the lung), elevated troponin, A fib, mixed respiratory and metabolic acidosis (condition where too much acid accumulates in the body and can be related to a buildup of body toxins or kidney failure) and embolic stroke (medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients). Review of the hospital’s untitled, undated document regarding the grievance of Patient #14 showed that the family filed a complaint with the hospital. The family stated they were concerned regarding her father’s ED visit on 12/03/23. Their father was seen and discharged home and came back via EMS on 12/04/23. He was intubated and placed in ICU. They stated that their father was in critical condition with multiple PEs in the lungs. The review was sent to Staff Y, Chief Medical Officer (CMO), for a peer review. Although requested, a peer review was not provided. During an interview on 5/22/24 at 10:50 AM, Staff G, ED Physician, stated that Patient #14 appeared to be in fluid overload in his opinion. He had no indication of having a PE. He did not order an ammonia level on him based on his symptoms. He believed the elevated troponin was a result of the fluid overload. He felt confident in discharging the patient as stable. During an interview on 05/23/24 at 9:00 AM, Staff N, ED Physician, stated that Patient #14 presented to the ED on 12/04/23 with significant altered mental status. He stated the grievance was reviewed at peer review and by the CMO. “The patient had a history of alcohol abuse and many medical problems that were all exacerbated at the time.” Review of Patient #25’s first ED medical record, dated 02/03/24 at 7:04 PM, showed a 53-year-old male who presented with complaints of right shoulder and elbow pain. His history included Covid (highly contagious, and sometimes fatal, virus) three weeks prior. He stated that he had taken extra strength Tylenol prior to his arrival. His initial temperature was 99.3 F, and he rated his pain as 9/10. He received anti-inflammatory, steroids, pain medication and a muscle relaxer. A viral panel swab was obtained along with a neck x-ray. He was diagnosed with nerve pain and discharged to home at 8:59 PM. Review of Patient #25’s second ED medical record, dated 02/05/24 at 11:07 AM, showed he returned to the ED for complaint of continued neck pain, radiating to right shoulder and arm. He denied any injury or trauma. At 12:28 PM, his temperature was 100.6 F, with a pain rating of 10/10. Diagnostic testing included an EKG and a CT scan of his neck. No laboratory testing was completed. CT results did not indicate any acute findings. He was discharged to home at 3:45 PM, with instructions to continue medications, obtain an outpatient Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body, and to follow up with orthopedics (medical specialty dealing with bones). Review of Patient #25’s History and Physical, dated 02/07/24 at 10:41 AM, showed he was seen by his primary care provider (PCP), with continued severe neck pain and inability to move. His PCP was concerned about possible infection. Laboratory testing an MRI were ordered. Review of Patient #25’s office visit addendum, dated 02/07/24 8:09 PM, showed the MRI results indicated soft tissue swelling in the mid to lower neck, potential abscess (collection or pocket of thick fluid caused by an infection) on the right side of the neck, and a possible infection of the bone in the upper back spine. Additional imaging was suggested. The patient was instructed to proceed to Hospital B for further evaluation. Review of Patient #25’s medical record from Hospital B, dated 02/07/24, showed he presented to the ED complaining of neck pain. His work-up from Ozarks Healthcare clinic showed an elevated WBC, an MRI concerning for an epidural abscess, and a diabetic wound on his foot that had a history of osteomyelitis. In the ED the patient had normal VS with moderate high blood pressure. He appeared uncomfortable but was not acutely distressed. His bloodwork showed an elevated WBC, slightly elevated inflammatory markers, a normal lactic acid and some kidney dysfunction. A chest x-ray was unremarkable, and a repeat MRI showed fluid collection causing some anterior canal narrowing, diffuse enhancement of the cauda equina (the sack of nerve roots at the lower end of the spinal cord) without mass effect, and abnormal paraspinal and epidural enhancement. The neurosurgery (a branch of medicine or surgery performed on the nervous system, especially the brain and spinal cord) consult recommended admission and antibiotics to prevent spinal epidural abscess. Surgery was performed on 02/08/24 for a posterior cervical fusion. He was treated in the neurotrauma ICU (an intensive care unit devoted to the care of patients with immediately life-threatening nervous system problems) after surgery and was intubated until 02/09/24. He remained in the hospital to manage his blood pressure, blood sugars, and an ileus (intolerance of oral intake due to inhibition of the GI propulsion without signs of mechanical obstruction) that developed. He was discharged on 02/21/24 with home health care to manage ongoing antibiotic infusions. Review of the hospital’s untitled, undated document regarding the grievance of Patient #25 showed at his ED visits no bloodwork was done and the pain medicine did not improve his symptoms. The complainant reported he was admitted to the Hospital B neurotrauma ICU (an intensive care unit devoted to the care of patients with immediately life-threatening nervous system problems) for sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs), surgery, and was on a ventilator (a machine that supports breathing). They noted discrepancies in the ED chart including failure to note the patient’s foot ulcer, documenting no fevers when fever was present, documenting no numbness or tingling, and failure to note the right-sided grip weakness. After review of the grievance, Staff G, ED Physician, felt the work-up was appropriate with the information given. During an interview on 05/22/24 at 10:50 AM, Staff G, ED Physician, stated that he believed the patient’s low-grade temperature was related to his respiratory symptoms and thought he had likely coughed or sneezed and messed up a disc. He arranged for Patient #25 to get the first possible outpatient MRI appointment because an MRI was not available in the ED. An epidural abscess would not be seen on a CT unless it was with contrast; however, the radiologists preferred an MRI. He did not consider labs at the time due to the upper respiratory infection (URI, irritation and swelling of the upper airways with associated cough and nasal congestion) symptoms. During an interview on 05/22/24 at 2:15 PM, Staff J, RN stated that she was unable to remember Patient #25. She reviewed the chart and her nursing assessment. She noted his pain score was 10/10 and he received pain medication but was unable to find a pain reassessment. During an interview on 05/23/24 at 8:25 AM, Staff BB, ED RN, stated that the co-medical directors (Staff G, ED Physician and Staff N, ED Physician) were the two physicians most likely to not assess their patients thoroughly unless you knew them personally. The assessments were often short and limited. 49489”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 39147 Based on interview and record review, the hospital failed to provide a safe transfer for one patient (#29) of 29 Emergency Department (ED) records reviewed from 11/24/23 through 05/23/24, when Patient #29 was transported by ground ambulance without a pediatric specialty transport team. This failure placed all patients requiring transfer at risk for their safety. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” dated 08/2022, showed an EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ. MSE is the process of determining whether or not an EMC exists. If the patient’s condition is outside the scope of services available, arrangements should be made to safely transfer the patient. A patient is stable for transfer if the treating provider attending to the patient has determined that the patient is expected to leave the hospital and be received at the second facility with no medical deterioration in medical condition. Requirements of the medical screening consists of a focused assessment based on the patient’s chief complaint sufficient to determine the presence or absence of an EMC. The MSE must provide evaluation and stabilizing treatment within the capabilities of the hospital. Review of Patient #29’s medical record from Ozarks Healthcare, dated 05/23/24, showed the patient was a 21-month-old male who arrived in the ED at 12:32 AM with a chief complaint of altered mental status (mental functioning ranging from slight confusion to coma). His grandparents reported he started vomiting on 05/20/24. He was seen as an outpatient on 05/21/24, diagnosed with a GI bug and sent home. During the evening of 05/22/24, he had decreased responsiveness and seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness)-like activity. He took no medications and there was no known trauma or ingestion of toxins. He was unresponsive to painful stimuli, had stiffened posture and his gaze was deviated toward the upper right. His pupils were pinpoint, equal, round, and reactive to light. He had no meningeal signs (nonspecific reactions that may occur in a patient with meningeal irritation). The staff administered Ativan, IV fluids and dextrose (sugar). The lab results showed a critically low sodium (a type of electrolyte in the blood, normal range 135-145) of 116, high potassium 5.7 (normal range 3.5-5), critically high creatine kinase (an enzyme found in the brain, skeletal muscles and the heart, an elevated level could be associated with damage to those areas, normal range 22-198) of 1,957, and blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health. Normal ranges are considered between 70 and 100) of 69. A respiratory pathogen panel later showed the patient had adenovirus and parainfluenza (family of viruses that can cause infections in the respiratory tract). His chest x-ray showed findings that could be seen in viral conditions versus reactive airway disease. Hospital D accepted transfer of the patient to the general pediatric floor. He was originally to be transferred by air, however, weather prevented air transport and EMS was dispatched. Review of the ambulance record for Patient #29 between Ozarks Health and Hospital D showed they left the hospital on 05/23/24 at 1:55 AM. The patient was saturating well on 1L of oxygen initially. The cardiac monitor showed a normal heart rhythm. His VS abruptly changed around 2:10 AM and Staff II, Paramedic, removed the patient from his car seat, started bagging (providing positive pressure ventilation to patients who are not breathing or not breathing adequately) and gave chest compressions. During the episode, five doses of epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) were administered. After the second loss of pulses, Staff II decided to divert to Hospital C for assistance. The patient had a return of spontaneous circulation (ROSC) upon arrival to Hospital C at 2:40 AM. Review of Patient #29’s medical record from Hospital C showed the patient arrived on 05/23/24 at 2:41 AM. He was immediately triaged and seen by a provider. He was ventilated with a laryngeal mask airway (LMA, a supraglottic airway device that may be used as a temporary method to maintain an open airway) after endotracheal intubation (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) was unsuccessful. He had additional bloodwork and a chest x-ray. The physician reported the patient’s problems included cardiac arrest (when the heart suddenly and unexpectedly stops pumping), acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), aspiration pneumonia (infection in the lungs caused by food or liquid entering the lungs instead of being swallowed), low blood pressure, low blood sugar, severe dehydration (a condition caused by excessive loss of water from the body), severely low sodium, and hypoxia (not enough oxygen reaching the cells and tissues in the body). He had a low core temperature of 90.0, fixed pupils, and abnormal heart rhythms. He was shocked with a defibrillator (a device that controls the heartbeat by applying an electric current to the chest wall or heart) three times. He was given IV antibiotics, IV hypertonic saline (a crystalloid intravenous fluid with a higher sodium concentration than normal blood serum, used in critical care to treat hyponatremia, severe dehydration, and brain injury), IV dextrose and calcium chloride (an inorganic salt compound). Once stabilized, he was transferred by ambulance to the Pediatric Intensive Care Unit (PICU, unit for ill children) at Hospital D at 3:44 AM. Air transport was declined by three helicopter services due to weather. Review of the Patient #29’s ambulance report from Hospital C to Hospital D showed he was unresponsive with an LMA, an orogastric tube (small tubes placed through the mouth and end with the tip in the stomach) and IVs in place. He had antibiotics, IV fluids, and dopamine (a peripheral vasostimulant) infusing. He remained stable during transport, although he had persistent low blood pressure. Report was given to the staff at Hospital D at 4:58 AM. Review of Patient #29’s medical record from Hospital D showed he arrived on 05/23/24 at 4:59 AM. An arterial line (thin, flexible tube placed into an artery) and central venous access (long, thin, flexible tube placed in a large vein and the end of the tube sits in a large blood vessel near to or in part of their heart, allowing multiple fluids to be given and blood to be drawn) were placed by Staff FF, Pediatric Intensivist. His LMA was replaced with an endotracheal tube (ETT, a tube inserted through the mouth or nose, that extends into the lungs, to maintain an open passageway for oxygen), a rewarming machine was utilized, and he was given IV vasopressors (a group of medicines that narrow blood vessels and raise blood pressure). He had no brain activity as assessed by electroencephalography (EEG, a recording of brain activity, often used to evaluate presence of seizure activity) and absent neurological reflexes (a sudden, instinctive and involuntary reaction to stimulation). The patient’s heart stopped at 9:15 PM and resuscitation was attempted for a while. He was pronounced dead at 9:35 PM due to worsening swelling and brain death. During an interview on 06/05/24 at 8:30 PM, Staff LL, Registered Nurse (RN), stated that she was working as the triage nurse when Patient #29 was brought in by grandparents. She saw that the child was unresponsive and immediately grabbed the patient and took him back to the trauma room. She stated that the ED physician and staff took over care. She stated that the grandparents seemed to be unaware of how serious the situation was. During an interview on 06/03/24 at 4:00 PM, Staff GG, RN, stated that she was one of the nurses who cared for Patient #29 at Ozarks Healthcare. She stated that when the grandparents arrived with the patient, a triage nurse noticed immediately that he seemed unresponsive and brought him directly to a room for treatment. The family reported he had vomiting and diarrhea for three to four days and started having episodes of unresponsiveness and grinding his teeth the day before. He was persistently unresponsive to IV needles and a urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) insertion. He started to have seizure-like activity and they administered Ativan and IV fluids. The seizure activity stopped after the medication and the patient seemed post-ictal (pertaining to the period after a seizure). Staff AA, ED Physician, arranged for the patient to be transferred to Hospital D. Staff GG recalled that when she called report to Hospital D, the lab results were not back yet. They learned about the critically low sodium level, “as they were rolling out to the ambulance.” Hypertonic saline was not available at the hospital, so they kept a normal saline solution infusing during transport. She was unaware if Staff AA had discussed starting an infusion of stronger seizure medications with the accepting doctor. At the time of transport, the patient was supporting his own airway with normal VS and intubation was not considered necessary. The amount of time the patient was treated at Ozarks Health was about one hour. During an interview on 06/04/24 at 10:30 PM, Staff MM, RN, stated that Patient #29 was floppy when he first arrived, but then his body stiffened up and he began to clench his teeth. They gave a dose of Ativan, checked his blood sugar, gave him IV fluids and dextrose. The family was oddly calm and seemed unaware of the emergent situation. The ED worked as a team, but the patient clearly needed pediatric specialists. The patient was on the EMS stretcher when lab started calling with critical labs. “This was a very sick child, and we did all we could to stabilize him.” During an interview on 06/10/24 at 5:45 PM, Staff AA, ED Physician, stated that Patient #29 arrived and was brought back by the triage nurse immediately. He stated that the patient was unresponsive, his body was limp and would then get stiff as if he was having a seizure. He ordered a dose of Ativan to be given for the seizure activity. He stated the nurses obtained IV access and attempted to get a urinalysis (a laboratory examination of a person’s urine) but when the nurse attempted, she was unable to get a urine sample. He stated that he immediately called Hospital D to arrange for a transfer. They attempted to call for air transport but were denied due to weather conditions. He stated they then called for an ambulance to transport the patient. At the time of discharge the patient had been stabilized as best as he could. He stated that as the patient was being wheeled out to the ambulance, they received critical lab results and he called Hospital D to let them know the results. He did not add any additional orders for transfer after receiving the critical lab results. During an interview on 06/05/24 at 10:20 AM, Staff NN, Pediatric Hospitalist from Hospital D, stated that he accepted Patient #29 for transfer to the general pediatric floor. The report he received from Staff AA, ED Physician, was that the patient had new onset seizure activity with recent viral gastric symptoms. At the time he took report there were no lab results back yet, the patient’s VS were stable, and his seizure activity had improved with one dose of Ativan. There was no discussion of starting any additional seizure medications prior to transfer. Nothing from the initial report indicated the patient required a higher level of care or more stabilization. During an interview on 06/04/24 at 12:35, Staff JJ, Emergency Medical Technician (EMT), stated that when she and Staff II, Paramedic, arrived at Ozarks Healthcare the patient was unresponsive, limp, cool, and pale. His vitals looked better than how he appeared physically. Staff II did not initially object to the patient not being intubated. She stated that when they diverted to Hospital C, that facility did so much more for the patient. His airway was managed and he was put on more stabilizing medications after they obtained ROSC. She stated this was an inappropriate transfer because there were too many missing puzzle pieces. It should have been a specialty team transporting who had more pediatric capability. During an interview on 06/04/24 at 12:20 PM, Staff II, Paramedic, stated that when he assessed Patient #29 at Ozarks Healthcare prior to transport, the patient was unresponsive. The nurse said the patient had been posturing with a gaze fixed to the right and his seizure activity ceased after medication. He stated this patient seemed worse than a typical post-ictal seizure patient. The staff had placed the patient on supplemental oxygen, but offered to remove it for transport since he was not struggling to breathe. Staff II told them to leave it on and considered whether the patient ought to be intubated. However, he didn’t feel comfortable questioning the physician. The staff didn’t initially have lab results, then as they were about to leave, they learned his sodium was critically low. They started a normal saline infusion and gave some dextrose but did not discuss any additional stabilization measures. During an interview on 06/03/24 at 5:20 PM, Staff FF, Pediatric Intensivist, stated that he cared for Patient #29 in the PICU at Hospital D on 05/23/24 throughout the day. Staff FF thought it was likely that the patient had worsening of swelling in his brain in the ambulance which caused it to herniate (a serious medical condition that occurs when brain tissue shifts from one part of the brain to another due to increased pressure within the skull) and then caused the patient’s heart to stop. When asked if this could have been prevented, Staff FF stated that “It’s hard to know for sure, possibly with hypertonic saline or intubation.” The patient was intubated at Hospital C and given hypertonic saline; however, by the time he arrived at Hospital D the patient was already brain dead. When asked about the family, Staff FF stated that they appropriately sought medical care earlier in the week for vomiting and diarrhea and were trying to give oral fluids. Unfortunately, the patient decompensated quickly. They seemed generally clueless and responded late, but he did not have concerns for neglect.”